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*Last Updated January 1, 1999*
BACKGROUND
Within the managed care arena, the role of the
geriatrician is rapidly expanding as a result of the growth of Medicare
risk programs. By January 1997, there were 4.9 million older adults
enrolled in 350 managed care programs. Most of these programs had
risk contracts in which the plan was capitated for the cost of care
for these patients. The number of members enrolled in managed care
capitated plans will most likely increase with the implementation
of Medicare Added Choices in January 1999. This contractual arrangement
allows for greater flexibility in the provision of care and has
the potential to improve the quality of care using approaches not
feasible in fee for service or cost reimbursement settings.
In capitated Medicare systems, a small subset
of members account for a disproportionate share of the high expenditures.
Thus, there is a need to create new models of care that both allow
for the higher cost member to receive needed services and distribute
costs more equitably. The framework of a managed care program with
a risk contract may include several features that enable this type
of innovative program development in providing care for older people.
Realizing the potential for Medicare risk programs necessitates
a population perspective, comprehensive data systems, prospective
capitated payment, an integrated delivery system, and variable incentive
compensation methods.
Most managed care plans have developed a service
delivery program designed for acute or episodic care for healthy,
younger adult members that comprise the vast majority of plan membership.
However, older patients’ characteristics differ from those of younger
members. Older adults have higher frequency of office visits, hospitalizations,
pharmaceutical use, and use of home health services compared with
younger members. Older members also have more chronic medical conditions,
have a more complex presentation of illness, and are slower to recover
from episodes of acute illness. Their clinical needs frequently
require complementary social supports for maintaining their level
of function.
Geriatricians stand alone in their capacity to
work within this framework to develop quality care and management
systems that meet both the clinical needs of the member and the
operational needs of the health plan.
POSITION 1
The geriatrician should serve in leadership positions
within managed care organizations to drive the necessary changes
in the delivery system to promote optimum care for all older adults.
Rationale
The geriatricians’ unique training allows them
to function in a variety of capacities, which include:
Designer of Special Geriatric Programs
To provide quality affordable medical care, special
programs are needed to care for older people. A geriatrician with
managerial skills can lead the design and implementation of these
programs. The geriatrician also provides the clinical perspective
essential in designing these special programs. Examples of such
programs include: screening and targeting programs; comprehensive
assessment clinics; group care clinics; proactive discharge planning
teams from acute and subacute venues; clinical pathways for care
of chronic conditions (i.e., congestive heart failure); preventive
outreach programs (i.e., influenza immunization); case management
for special needs patients; home care programs; special inpatient
units (i.e., GEM or Acute Care for the Elderly units); and health
education programs in wellness and self-management.
Administrator for Operational Geriatric Programs
Placing the geriatrician as the administrative
head of geriatric service delivery programs allows for necessary
collaboration among managers that can impact the delivery of services
to older people. A full time manager, equipped with either a masters
level nursing or health care administrative background, should collaborate
with the geriatrician. Together they can oversee efficient deployment
of resources within the program. The scope of their oversight should
include daily staff operations, utilization management of resources
used by older people, supervision and evaluation of personnel, and
oversight of clinical care delivered. They should have oversight
of all of the clinical geriatric venues. This would include supervision
of interdisciplinary teams that provide comprehensive geriatric
assessments in acute, subacute, or ambulatory care settings; care
delivered in the home by clinicians and home health agencies; and
discharge planning teams from hospital or long-term care settings.
Liaison to Other Departments
The entire healthcare delivery system is touched
by the older member. Facilities or systems of care serving older
adults are required to interface internally and externally with
many services for both clinical and business reasons. Careful adaptation
of services to meet the needs of older people is crucial to the
financial success of the organization. Such service networks include
marketing, pharmacy contracts and formulary development, provider
and payor contracts, internal and external quality review boards,
and utilization review boards. The geriatrician can provide the
insight and clinical experience to address the unique needs and
issues for the older patient and member. Such input can help direct
the optimal use of resources and outline meaningful outcome indicators
that benefit not only the older person but the system of care as
well.
Organizational Executive
At the governance level, the geriatrician can
provide essential leadership to an organization by articulating
service priorities, the allocation of resources, and the definition
of outcome measurements that optimize clinical and financial performance
of the organization. The geriatrician as executive can help move
a system of care beyond a collection of independent services and
facility-based approaches to cost accounting to an integrated process
of care delivery with shared organization incentives, information
systems, and flexible care delivery that meets the needs of the
frail older population.
POSITION 2
The geriatrician should be utilized as an expert
resource for knowledge and training for clinicians and other health
plan staff for geriatrics and gerontology.
Rationale
Educator for Geriatrics and Gerontology
Across a healthcare system, in both inpatient
and outpatient settings, there is a clear need for geriatric education.
The majority of practicing clinicians have not had formal training
in the field of geriatrics. This spans the areas of content from
clinical management of the older patient (i.e., medication management
or the presentation of geriatric syndromes) to functional and behavioral
assessments (i.e., the use of physical restraints or creating an
elder-friendly environment). The geriatrician is the ideal person
to identify areas of need, create specific curricula, and provide
direct teaching to other healthcare professionals. The geriatrician
can use existing venues, including departmental meetings, organizational
newsletters, consultation reports, and continuing medical education
programs, to meet educational objectives.
POSITION 3
The geriatrician should be utilized as the clinical
expert in the care of complex/frail older adults.
Rationale
Provision of primary and consultative care for
complex/frail older people often involves practicing in a variety
of settings outside of the clinic and acute care hospital. These
settings include geriatric assessment clinics, subacute and traditional
skilled nursing facilities, assisted living and adult day healthcare
centers, residential care, and home health, hospice, and PACE programs.
Providing care in these locations differs not only by the logistics
of the site, but also by the roles of the healthcare team members.
Each setting requires knowledge of the services available and how
to manage the clinical, functional, and support needs of older people
at that level of care. As part of a geriatric fellowship, geriatricians
are trained to provide clinical expertise to care for complex/frail
older people in these settings with interdisciplinary teams. The
geriatrician can optimize care, minimize unnecessary transfers,
and direct a more appropriate utilization of resources while meeting
the special needs of the frail older person.
Prepared by Adrienne D. Mims, MD, MPH, and approved
by the AGS Health Care Systems Committee and the AGS Board of Directors,
May 1999. AGS, The Empire State Building, 350 Fifth Avenue, Suite
801, New York, NY 10118.
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